2014-05-14T06:42:21-05:00 2013-06-30 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2012-07-01 460224604 AVERA QUEEN OF PEACE HOSPITAL AVER 6059952251 525 NORTH FOSTER STREET MITCHELL SD 57301 WILLIAM E FLETT 6059952251 2014-05-13 0 KIM HUNWARDSEN CPA P00484560 6122536500 2014-05-13 2012 2015-11-30 17:44:51Z AVERA QUEEN OF PEACE HEALTH SERVICE THOMAS A CLARK 525 NORTH FOSTER STREET MITCHELL SD 57301 98726059 0 0928 X WWW.AVERAQUEENOFPEACE.ORG X 1905 SD PROMOTION OF HEALTH 18 13 998 120 0 0 299594 1738160 91771776 94804644 1356570 1906582 -185416 -289504 93242524 98159882 205016 540476 0 0 52453229 54118975 0 0 189546 35084825 37618998 87743070 92278449 5499454 5881433 111663788 115213085 35720424 33371299 75943364 81841786 X AVERA IS A HEALTH MINISTRY ROOTED IN THE GOSPEL. OUR MISSION IS TO MAKE A POSITIVE IMPACT IN THE LIVES AND HEALTH OF PERSONS AND COMMUNITIES BY PROVIDING QUALITY SERVICES GUIDED BY CHRISTIAN VALUES. 0 0 75679528 540476 94804644 AVERA QUEEN OF PEACE'S MISSION IS TO PROVIDE HEALTHCARE SERVICES TO MITCHELL, SD RESIDENTS AND THE SURROUNDING AREA. THEY PROVIDE ACUTE CARE AND LONG-TERM HEALTHCARE SERVICES, OF WHICH THERE WERE 8,074 ACUTE PATIENT DAYS, 2,383 SWING-BED PATIENT DAYS, 1,056 NURSERY PATIENT DAYS, 29,530 NURSING HOME RESIDENT DAYS, 8,792 ASSISTED LIVING RESIDENT DAYS, AND 2,006 INDEPENDENT LIVING DAYS. THE BREAKOUT OF THESE STATISTICS PER FACILITY IS AS FOLLOWS.AVERA QUEEN OF PEACE HOSPITAL7,742 ACUTE PATIENT DAYS1,714 SWING-BED PATIENT DAYS1,056 NEWBORN PATIENT DAYSAVERA BRADY HEALTH AND REHABILITATION29,530 LONG-TERM CARE RESIDENT DAYS8,792 ASSISTED LIVING DAYS2,006 INDEPENDENT LIVING DAYSAVERA WESKOTA MEMORIAL MEDICAL CENTER (CAH)199 ACUTE PATIENT DAYS413 SWING-BED PATIENT DAYSAVERA DE SMET MEMORIAL HOSPITAL (CAH)133 ACUTE PATIENT DAYS256 SWING-BED PATIENT DAYS AVERA QUEEN OF PEACE MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY AND EQUIVALENT SERVICE STATISTICS. THE AMOUNT OF CHARGES FOREGONE, BASED ON ESTABLISHED RATES, WERE $2,130,534.AVERA QUEEN OF PEACE ALSO PROVIDES COMMUNITY BENEFIT HEALTH ACTIVITIES AT LESS THAN OR AT NO COST TO SUPPORT THOSE IN THE AREA SERVICED. THESE ACTIVITIES INCLUDE COMMUNITY EDUCATION PROGRAMS; SPECIAL PROGRAMS FOR THE ELDERLY, HANDICAPPED, AND MEDICALLY UNDERSERVED; AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. DURING THE YEAR ENDED JUNE 30, 2013, SPECIFIC ACTIVITIES INCLUDE MEALS DELIVERED TO RESIDENTIAL HOMES; MEETING FACILITIES; PROGRAMS FOR PATIENTS AND FAMILIES SUFFERING FROM CANCER, DIABETES, BREATHING DISORDERS, AND OTHERS; ASSISTANCE TO HEALTH EDUCATORS; EMERGENCY HEALTHCARE PROVIDERS; WELLNESS PROGRAMS; AND OVERNIGHT HOUSING FOR FAMILIES OF HOSPITALIZED PATIENTS.AS A MEMBER OF THE AVERA HEALTH NETWORK, AVERA QUEEN OF PEACE UPHOLDS THE VISION OF THE PRESENTATION AND BENEDICTINE SISTERS TO WORK THROUGH COLLABORATION TO PROVIDE A QUALITY, EFFECTIVE HEALTH MINISTRY AND TO IMPROVE THE HEALTH CARE OF INDIVIDUALS AND OUR COMMUNITIES THROUGH A REGIONALLY INTEGRATED NETWORK OF PERSONS AND INSTITUTIONS. AVERA QUEEN OF PEACE ENGAGES IN ACTIVITIES DESIGNED TO IMPROVE THE HEALTH OF INDIVIDUALS AND COMMUNITIES IN RESPONSE TO A CALLING TO HEAL THE SICK, THE ELDERLY, AND THE OPPRESSED. 75679528 1 1 0 1 0 0 0 0 1 1 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 1 0 0 0 0 0 1 1 0 0 0 1 174 0 1 998 1 0 0 0 0 0 0 0 0 0 0 X 18 13 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X WILL FLETT 6059952251 525 NORTH FOSTER MITCHELL SD 57301 LORI ESSIG 2.50 0.00 X X 0 0 0 TERRY TORGERSON 2.50 0.00 X X 0 0 0 LOREN NOESS 2.50 0.00 X 0 0 0 CHARLES BERGELEEN 2.50 0.00 X 0 0 0 SISTER KATHLEEN CROWLEY 2.50 10.00 X 0 0 0 DENNIS KRUSE 2.50 0.00 X 0 0 0 SISTER BONITA GACNIK 2.50 0.00 X 0 0 0 DAVID OLSON 2.50 0.00 X 0 0 0 JACQUELYN JOHNSON 2.50 0.00 X 0 0 0 KELLY SMITH MD 2.50 0.00 X 60103 0 0 DIANE SANDHOFF 2.50 0.00 X 0 0 0 JERRY THOMSEN 2.50 0.00 X 0 0 0 ROGER MUSICK 2.50 0.00 X 0 0 0 MICHAEL KRAUSE DO 2.50 0.00 X 13333 0 0 PATRICIA MALTERS MD 2.50 0.00 X 267446 0 20300 GREG VAN WALD 2.50 0.00 X 0 0 0 SISTER JOAN REICHELT 2.50 3.30 X 0 0 0 JENNIFER TEGETHOFF 2.50 0.00 X 333197 0 24042 THOMAS CLARK 40.00 0.00 X X 0 370576 46366 WILLIAM E FLETT 40.00 0.00 X 136500 0 32879 BRIAN KAMPMANN MD 40.00 0.00 X 824297 0 41734 STEPHEN DICK MD 40.00 0.00 X 423437 0 39914 CHRISTOPHER KROUSE MD 40.00 0.00 X 1007698 0 39914 MICHAEL HALEY MD 40.00 0.00 X 518881 0 44734 DENNIS LELAND MD 40.00 0.00 X 627978 0 43235 4212870 370576 333118 51 0 1 0 AVERA HEALTH 3900 W AVERA DRIVE SUITE 300 SIOUX FALLS SD 57108 SHARED SERVICES 4248762 CLARO GROUP LLC 321 N CLARK ST STE 1200 CHICAGO IL 60654 CONSULTING SERVICES 300425 AEGIS THERAPIES INC PO BOX 8103 FORT SMITH AR 72902 PHYSICAL AND OCCUPATIONAL THERAPY 277245 DMS IMAGING LTD 26273 NETWORK PL CHICAGO IL 60673 NUCLEAR MEDICINE SERVICES PET SCANS 225120 PUETZ CORPORATION 800 N KIMBALL MITCHELL SD 57301 CONSTRUCTION SERVICES 175629 7 1584127 154033 1738160 NET PATIENT & RESIDENT SERVICES 622110 92281656 92281656 OTHER REVENUE 900099 1473388 1473388 CAFETERIA 900099 483022 483022 INTEREST IN AVERA HEALTH FND 900099 454295 454295 COMMUNITY WELLNESS 900099 112283 112283 94804644 120196 120196 276673 566177 -289504 -289504 -289504 1758384 28002 0 0 1758384 28002 1786386 1786386 98159882 94804644 0 1617078 540476 540476 866194 672283 193911 265777 265777 41438204 34995195 6307268 135741 2394350 2022058 364477 7815 6548629 5527889 999489 21251 2605821 2199573 397909 8339 9092495 4463179 4629316 441506 40155 401351 8819446 6800129 2006076 13241 250744 151922 98822 2034377 1366368 668009 266712 184192 80381 2139 126952 46039 79893 1020 694130 694130 4119345 4119345 788502 788502 MEDICAL SUPPLIES 6989975 6989975 BAD DEBT EXPENSE 3248249 3248249 EQUIPMENT LEASE AND REN 170305 110578 59727 GRANT PROGRAM EXPENDITU 104383 104383 471877 349131 122746 92278449 75679528 16409375 189546 3368813 4401190 1292 1813 12573812 13089118 39762 5180 1234335 1320954 957408 1461874 96536405 55390577 38003278 41145828 924180 938557 51789691 49838610 292572 1055564 200000 2478645 1754397 111663788 115213085 7863100 8094367 33476 46409 23448866 22845170 4374982 2385353 35720424 33371299 X 73165461 78648850 1981585 2392230 796318 800706 75943364 81841786 111663788 115213085 X 5881433 1632968 -1615979 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8303 8303 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: AVERA QUEEN OF PEACE HOSPITAL PAID DUES TO ORGANIZATIONS WHICH HAVE A PORTION OF THE DUES ATTRIBUTED TO LOBBYING ACTIVITIES. 0 1 X 1040814 24205 1065019 1034190 6624 1040814 793583 109334 131273 1034190 1032880 -239297 793583 1028163 4717 1032880 0.12780 0.75180 0.12040 0 1 1 448669 2863464 3312133 1830496 52936601 28724932 26042165 35083425 25464318 9619107 3373750 1201327 2172423 41145828 INVESTMENT IN AFFILIATED ORGANIZATIONS 202981 C INTEREST IN AVERA HEALTH FOUNDATION 2852897 F INTEREST IN NET ASSETS OF MABEE TRUST 797190 F ASSETS LIMITED TO USE - AVERA POOLED INVESTMENTS 45985542 F 49838610 DERIVATIVE LIABILITY 2054253 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 331100 2385353 X 96942736 1632968 -2323786 -690818 97633554 526328 526328 98159882 89030200 0 89030200 3248249 3248249 92278449 PART IV, LINE 2B: THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF ITS RESIDENTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION'S ENDOWMENTS CONSIST OF A PORTION OF THEIR INTEREST IN THE NET ASSETS OF AVERA HEALTH FOUNDATION AND THEIR BENEFICIAL INTEREST IN THE MABEE TRUST. AVERA HEALTH FOUNDATION INCLUDES ENDOWMENT FUNDS WHICH HAVE BEEN ESTABLISHED FOR A VARIETY OF PURPOSES. THE ENDOWMENT FUND ASSETS INCLUDED IN THE ORGANIZATION'S BENEFICIAL INTEREST IN THE MABEE TRUST HAVE BEEN ESTABLISHED TO PURCHASE EQUIPMENT AND FURNISHINGS FOR THE ORGANIZATION. AS REQUIRED BY GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, NET ASSETS ASSOCIATED WITH ENDOWMENT FUNDS, INCLUDING FUNDS DESIGNATED BY THE BOARD OF DIRECTORS TO FUNCTION AS ENDOWMENTS (IF ANY), ARE CLASSIFIED AND REPORTED BASED ON THE EXISTENCE OR ABSENCE OF DONOR-IMPOSED RESTRICTIONS. THE ORGANIZATION'S PERMANENTLY RESTRICTED ENDOWMENT FUNDS ARE DONOR RESTRICTED. THE ORGANIZATION CURRENTLY DOES NOT HAVE ANY BOARD-DESIGNATED ENDOWMENT FUNDS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION IS ORGANIZED AS A SOUTH DAKOTA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE ORGANIZATION IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE ORGANIZATION IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE ORGANIZATION FILES AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT ITS UNRELATED BUSINESS TAXABLE INCOME. THE ORGANIZATION BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE ORGANIZATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE ORGANIZATION'S FEDERAL FORM 990T FILINGS ARE NO LONGER SUBJECT TO FEDERAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2010. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 984,972. RECLASSIFICATION OF ACCUMULATED LOSSES ON INTEREST RATE SWAP -60,509. PROVISION FOR BAD DEBTS INCLUDED IN REVENUE ON FINANCIAL STATEMENTS -3,248,249. PART XI, LINE 4B - OTHER ADJUSTMENTS: GRANTS AND CONTRIBUTIONS RECORDED IN FUND BALANCE FOR FINANCIAL STATEMENTS 33,577. CHANGE IN INTEREST IN AVERA FOUNDATION RECORDED IN FUND BALANCE FOR F/S 413,998. CHANGE IN INTEREST IN MABEE TRUST RECORDED IN FUND BALANCE FOR F/S 78,753. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS INCLUDED IN REVENUE ON FINANCIAL STATEMENTS 3,248,249. 1 1 X 1 X 1 X 1 1 1 0 1 1 865765 865765 0.00970 6947 7702816 5043418 2659398 0.02990 6947 8568581 5043418 3525163 0.03960 21 83661 98953 1205 97748 0.00110 4 1 71657 71657 0.00080 3 5893 950990 626459 324531 0.00360 46 42619 315185 315185 0.00350 74 132174 1436785 627664 809121 0.00900 74 139121 10005366 5671082 4334284 0.04860 1 350 740 740 0.00000 1 3227 3227 0.00000 1 11321 67926 45284 22642 0.00030 1 95 953 953 0.00000 4 11766 72846 45284 27562 0.00030 1 3248249 0 29954979 38570952 -8615973 X 1 1 3 1 AVERA QUEEN OF PEACE HOSPITAL

525 NORTH FOSTER STREET MITCHELL SD 57301

X X X 5 PROVIDER BASED CLINICS 2 AVERA WESKOTA MEMORIAL MEDICAL CENTER

609 1ST STREET NE WESSINGTON SPRINGS SD 57382

X X X 3 AVERA DE SMET MEMORIAL HOSPITAL

306 PRAIRIE AVENUE SW DE SMET SD 57231

X X X AVERA QUEEN OF PEACE HOSPITAL 1 1 X X X X X X X 12 1 0 1 X X X X X X X X 0 0 1 1 150.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 1 AVERA WESKOTA MEMORIAL MEDICAL CENTER 2 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X 0 0 1 1 150.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 1 AVERA DE SMET MEMORIAL HOSPITAL 3 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X X X 0 0 1 1 150.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 1 2 AVERA BRADY ASSISTED LIVING

1414 W CEDAR AVE MITCHELL SD 57301

ASSISTED LIVING AVERA BRADY HEALTH AND REHAB

500 S OHMAN ST MITCHELL SD 57301

NURSING HOME PART I, LINE 3C: TO DETERMINE ELIGIBILITY FOR CHARITY CARE, AVERA QUEEN OF PEACE HOSPITAL HAS DEVELOPED A TEST WHICH UTILIZES A COMBINATION OF HOUSEHOLD INCOME, HOUSEHOLD ASSETS, AND ALSO CONSIDERS UNPAID PAST AND ONGOING MEDICAL EXPENSES. CHARITY DISCOUNT MAY RANGE FROM 10 - 100% DEPENDING ON SCORE. PART I, LINE 6A: PART 1, LINE 6A: OUR COMMUNITY BENEFIT REPORT IS CONTAINED IN A REPORT PREPARED BY AVERA HEALTH, A RELATED ORGANIZATION. IT IS AVAILABLE THROUGH THE WEBSITE AND REQUESTED MAILING, AND IS FILED WITH THE CATHOLIC HEALTH ASSOCIATION. PART I, LINE 7: CHARITY CARE AND UNREIMBURSED MEDICAID WAS CONVERTED TO COST USING THE COST TO CHARGE RATIO IN IRS WORKSHEET 2. THE AMOUNTS ON LINES 7E-I REPRESENT EXPENSES REPORTED IN THE GENERAL LEDGER. PART I, L7 COL(F): AQOP BAD DEBT EXPENSE OF $3,248,249 IS INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A) BUT EXCLUDED FOR PURPOSES OF CALCULATING THIS PERCENTAGE. PART II: AVERA QUEEN OF PEACE SUPPORTS NUMEROUS ECONOMIC DEVELOPMENT ORGANIZATIONS WITH PARTICIPATION AT MEETINGS AND DONATIONS THROUGHOUT ITS SERVICE AREA. ADDITIONALLY, AVERA QUEEN OF PEACE WORKS WITH DAKOTA WESLEYAN UNIVERSITY, THE MITCHELL TECHNICAL INSTITUTE, AND LOCAL HIGH SCHOOLS TO ADDRESS HEALTHCARE WORKER SHORTAGES IN THE COMMUNITIES OF ITS SERVICE AREA. PART III, LINE 4: BAD DEBT IS REPORTED AT CHARGES AS RECORDED BY THE ORGANIZATION. BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR. AVERA QUEEN OF PEACE DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE SINCE EVALUATIONS ARE COMPLETED TO DETERMINE THOSE AMOUNTS DUE AND WILL BE RECLASSIFIED FROM BAD DEBT EXPENSE TO CHARITY CARE WITHIN 30 DAYS FOLLOWING THE EVALUATION OF THE AMOUNT.THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSES IS LOCATED IN FOOTNOTE 1 ON PAGE 7 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. AVERA QUEEN OF PEACE FOLLOWS THE CHA GUIDELINES IN REPORTING COMMUNITY BENEFITS AND THEREFORE ANY MEDICARE SHORTFALL (AS CALCULATED INCLUDING OUR NON-COST REPORT ENTITIES) IS EXCLUDED FROM OUR COMMUNITY BENEFIT REPORT. HOWEVER, MEDICARE IS THE ORGANIZATION'S LARGEST PAYER AND PATIENTS WITH MEDICARE COVERAGE ARE ACCEPTED REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED FROM PROVIDING THE SERVICES. THIS BASIS THEREFORE MEANS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A KEY ADVANTAGE FOR OUR COMMUNITY. PART III, LINE 9B: IF THE PATIENT QUALIFIES FOR THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME, UNINSURED PATIENTS AND IS COOPERATING WITH THE ORGANIZATION WITH REGARD TO EFFORTS TO SETTLE AN OUTSTANDING BILL WITHIN A REASONABLE TIME PERIOD, THE ORGANIZATION OR ITS AGENT SHALL NOT SEND, NOR INDICATE THAT IT WILL SEND, THE UNPAID BILL TO ANY OUTSIDE AGENCY IF DOING SO MAY NEGATIVELY IMPACT A PATIENT'S CREDIT. AT SUCH TIME AS THE ORGANIZATION SENDS THE UNCOLLECTED ACCOUNT TO AN OUTSIDE COLLECTION AGENCY, THE AMOUNT REFERRED TO THE AGENCY SHALL REFLECT THE REDUCED-PAYMENT LEVEL FOR WHICH THE PATIENT WAS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME UNINSURED PATIENTS. ANY EXTENDED PAYMENT PLANS OFFERED BY A HOSPITAL IN SETTLING THE OUTSTANDING BILLS OF LOW INCOME, UNINSURED PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SHALL BE INTEREST-FREE SO LONG AS THE REPAYMENT SCHEDULE IS MET. AVERA QUEEN OF PEACE HOSPITAL PART V, SECTION B, LINE 3: SIX FOCUS GROUPS WERE HELD TO COLLECT PRIMARY DATA FROM COMMUNITY LEADERS, SENIOR CITIZENS, SINGLE PARENTS, SMALL BUSINESS REPRESENTATIVES, LARGE BUSINESS REPRESENTATIVES, AND POST-SECONDARY STUDENTS. IN ADDITION, THE FOLLOWING INDIVIDUALS WERE CONSULTED IN CONDUCTING THE NEEDS ASSESSMENT: PRINCIPAL, LONGFELLOW ELEMENTARY SCHOOL; DIRECTOR OF ADULT SERVICES AND AGING, DAVISON COUNTY; PUBLIC HEALTH NURSE, DAVISON COUNTY; DIRECTOR OF FAMILY PLANNING, DAVISON COUNTY; AND PARISH HEALTH NURSE, FIRST LUTHERAN CHURCH. AVERA WESKOTA MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 3: AVERA WESKOTA MEMORIAL HOSPITAL GATHERED BOTH SECONDARY AND PRIMARY DATA FOR THE ASSESSMENT. A COMMUNITY DEVELOPMENT SPECIALIST WITH THE PLANNING AND DEVELOPMENT DISTRICT GATHERED PRIMARY DATA BY CONDUCTING FOCUS GROUPS AND A NUMBER OF KEY INFORMANT INTERVIEWS. AVERA WESKOTA ALSO COLLECTED PRIMARY DATA THROUGH A SURVEY TOOL. THE SURVEY WAS UTILIZED TO REACH THE BROADER COMMUNITY AND WAS DISTRIBUTED TO THE FOLLOWING FOUR GROUPS OF PEOPLE THROUGHOUT THE WESSINGTON SPRINGS AREA: 1) COMMUNITY & COUNTY MEMBERS 2) HEALTH CARE PROVIDERS, STAFF & BOARD MEMBERS 3) UNINSURED/UNDERINSURED POPULATIONS & 4) COMMUNITY LEADERS. AVERA DE SMET MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: INPUT WAS GATHERED FROM INDIVIDUALS REPRESENTING THE FOLLOWING GROUPS: PUBLIC SAFETY, HEALTHCARE, LOW INCOME, CONTRACTORS/SELF EMPLOYED, SCHOOLS, SD DEPT OF HEALTH OFFICE OF RURAL HEALTH AVERA QUEEN OF PEACE HOSPITAL PART V, SECTION B, LINE 5C: THE CHNA IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA WESKOTA MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 5C: THE CHNA IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA DE SMET MEMORIAL HOSPITAL PART V, SECTION B, LINE 5C: THE CHNA IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA QUEEN OF PEACE HOSPITAL PART V, SECTION B, LINE 6I: THE IMPLEMENTATION STRATEGY IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA WESKOTA MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 6I: THE IMPLEMENTATION STRATEGY IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA DE SMET MEMORIAL HOSPITAL PART V, SECTION B, LINE 6I: THE IMPLEMENTATION STRATEGY IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA QUEEN OF PEACE HOSPITAL PART V, SECTION B, LINE 7: ADEQUATE AND AFFORDABLE HOUSING: AVERA QUEEN OF PEACE CURRENTLY HAS REPRESENTATION ON THE MITCHELL DEVELOPMENT CORPORATION. THE MITCHELL DEVELOPMENT CORPORATION IS ACTIVE IN ATTRACTING INVESTMENT IN AFFORDABLE HOUSING.AFFORDABLE DENTAL CARE: A MOBILE DENTAL CARE CLINIC CURRENTLY ASSISTS LOCAL DENTIST IN PROVIDING FREE DENTAL SERVICES TO NEEDY CHILDREN. OUR FINDINGS OF PATIENTS ARE UNABLE TO FIND A DENTIST WITH AVAILABLE APPOINTMENTS OR WILLING TO ACCEPT UNINSURED PATIENTS WILL BE COMMUNICATED WITH DENTISTS. AFFORDABLE AND RELIABLE PUBLIC TRANSPORTATION: THE CITY OF MITCHELL CURRENTLY OPERATES A PUBLIC TRANSIT SYSTEM, IN ADDITION, A LOCAL COMPANY ALSO PROVIDES TRANSPORTATION SERVICES. OUR FINDINGS OF WAIT TIMES FOR TRANSPORTATION HAVE BEEN COMMUNICATED WITH TRANSPORTATION PROVIDERS. AVERA WESKOTA MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 7: LACK OF ASSISTED LIVING HOUSING: THIS FINDING WAS REPORTED TO THE LOCAL NURSING HOME BOARD OF DIRECTORS TO ADDRESS IN THEIR STRATEGIC PLANNING AS THEY CURRENTLY PROVIDE INDEPENDENT SENIOR HOUSING AND MAY BE ABLE TO ADD OR CONVERT SPACE FOR ASSISTED LIVING. AVERA DE SMET MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: DUE TO LIMITED FINANCIAL, PHYSICAL SPACE AND TIME LIMITATIONS, THE INTERDISCIPLINARY CHNA TEAM DID NOT PRIORITIZE/ASSIGN FOR IMPLEMENTATION AT THIS TIME: WATER QUALITY: ALL COMMENTS AND CONCERNS WILL BE ADDRESSED BY THE CITY OF DE SMET.PHYSICAL ACTIVITY: THE CITY OF DE SMET IS ADDRESSING THE WELLNESS NEEDS OF THE COMMUNITY WITH PLANS FOR CONSTRUCTION OF A COMMUNITY CENTER AND WELLNESS CENTER.DOMESTIC ABUSE: THIS NEED WILL BE ADDRESSED BY THE BROOKINGS ABUSE SHELTER RURAL OUTREACH PROGRAM AS THIS PROGRAM IS BEST QUALIFIED TO ADDRESS THIS NEED. AVERA QUEEN OF PEACE HOSPITAL PART V, SECTION B, LINE 14G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS POSTED IN THE HOSPITAL FACILITY'S EMERGENCY ROOMS, WAITING ROOMS, AND ADMISSIONS OFFICE AND INCLUDED IN THE BILLING STATEMENT. IN ADDITION, THE FINANCIAL ASSISTANCE POLICY IS DISCUSSED WITH THE PATIENT UPON ADMISSION TO THE FACILITY. AVERA WESKOTA MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 14G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS POSTED IN THE HOSPITAL FACILITY'S EMERGENCY ROOMS, WAITING ROOMS, AND ADMISSIONS OFFICE AND INCLUDED IN THE BILLING STATEMENT. IN ADDITION, THE FINANCIAL ASSISTANCE POLICY IS DISCUSSED WITH THE PATIENT UPON ADMISSION TO THE FACILITY. AVERA DE SMET MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS POSTED IN THE HOSPITAL FACILITY'S EMERGENCY ROOMS, WAITING ROOMS, AND ADMISSIONS OFFICE AND INCLUDED IN THE BILLING STATEMENT. IN ADDITION, THE FINANCIAL ASSISTANCE POLICY IS DISCUSSED WITH THE PATIENT UPON ADMISSION TO THE FACILITY. AVERA QUEEN OF PEACE HOSPITAL PART V, SECTION B, LINE 22: INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE ARE NOT CHARGED GROSS CHARGES FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE; HOWEVER MAY BE CHARGED GROSS CHARGES FOR ELECTIVE CARE. AVERA WESKOTA MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 22: INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE ARE NOT CHARGED GROSS CHARGES FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE; HOWEVER MAY BE CHARGED GROSS CHARGES FOR ELECTIVE CARE. AVERA DE SMET MEMORIAL HOSPITAL PART V, SECTION B, LINE 22: INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE ARE NOT CHARGED GROSS CHARGES FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE; HOWEVER MAY BE CHARGED GROSS CHARGES FOR ELECTIVE CARE. PART VI, LINE 2: AVERA QUEEN OF PEACE CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENTS FOR EACH FACILITY DURING 2012 AND 2013. THE CHNA IMPLEMENTATION PLANS FOR AVERA WESKOTA MEMORIAL MEDICAL CENTER AND AVERA DE SMET MEMORIAL HOSPITAL WERE ADOPTED BY THE AVERA QUEEN OF PEACE GOVERNING BOARD ON MAY 28, 2013. THE CHNA IMPLEMENTATION PLAN FOR AVERA QUEEN OF PEACE HOSPITAL WAS ADOPTED BY THE AVERA QUEEN OF PEACE GOVERNING BOARD ON JUNE 25, 2013. PART VI, LINE 3: ANYONE WHO IS UNINSURED RECEIVES A LETTER WITH THEIR ITEMIZED BILL WHICH DESCRIBES BOTH THE UNINSURED PROGRAM AND THE CHARITY CARE PROGRAM. ANY UNINSURED PATIENT IS CONTACTED BY PHONE OR LETTER BY OUR COLLECTIONS DEPARTMENT AT WHICH TIME OUR PROGRAMS ARE DESCRIBED. ALSO, INPATIENT AND SAME DAY SURGERY PATIENTS RECEIVE A BROCHURE IN THEIR ADMISSIONS PACKET. PRE-COLLECTION LETTERS ALSO INCLUDE INFORMATION REGARDING OUR CHARITY CARE AND UNINSURED PROGRAMS. PART VI, LINE 4: AVERA QUEEN OF PEACE'S SERVICE AREA INCLUDES DAVISON COUNTY AND SURROUNDING COUNTIES IN SOUTH DAKOTA. IN 2010, THE POPULATION FOR DAVISON COUNTY WAS ESTIMATED TO BE 19,504. APPROXIMATELY 16.9% OF THE POPULATION IS AGE 65 OR OLDER. THE AVERAGE PER CAPITA INCOME IS $23,510 AND APPROXIMATELY 12% OF INDIVIDUALS ARE BELOW THE FEDERAL POVERTY LEVEL. THE NEAREST HOSPITAL IN THE AREA IS APPROXIMATELY 22 MILES FROM AVERA QUEEN OF PEACE. PART VI, LINE 5: AVERA QUEEN OF PEACE IS A VERIFIED LEVEL II TRAUMA CENTER AND OPERATES AN EMERGENCY DEPARTMENT STAFFED 24 HOURS PER DAY WITH BOARD CERTIFIED PHYSICIANS. EMERGENCY CARE IS PROVIDED ON AN OPEN DOOR BASIS REGARDLESS OF ABILITY TO PAY. AVERA QUEEN OF PEACE LEASES TWO CRITICAL ACCESS HOSPITALS WHICH PROVIDE A BROAD RANGE OF INPATIENT, OUTPATIENT SERVICES AND 24 HOUR EMERGENCY ROOMS IN TWO VERY RURAL COMMUNITIES.AVERA QUEEN OF PEACE OWNS THREE RURAL HEALTH CLINICS WHICH PROVIDE PRIMARY CARE SERVICES IN THREE RURAL COMMUNITIES.SIMILAR TO THE HOSPITALS IN THE AQOP REGION, THESE CLINICS ARE OPERATED ON AN OPEN DOOR BASIS AND CARE IS PROVIDED REGARDLESS OF ABILITY TO PAY.MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL LICENSED AND QUALIFIED APPLICANTS. THE AVERA QUEEN OF PEACE BOARD OF DIRECTORS IS PRINCIPALLY COMPRISED OF COMMUNITY MEMBERS FROM THE PRIMARY AND SECONDARY SERVICES AREAS. MEMBERS COME FROM A VARIETY OF BACKGROUNDS INCLUDING BANKING, EDUCATION, AGRICULTURE, HEALTHCARE AND PRIVATE INDUSTRY. PART VI, LINE 6: THE COMMUNITIES IN WHICH AVERA OPERATES ALL HAVE UNIQUE HEALTH AND COMMUNITY BENEFIT NEEDS AND IN KEEPING WITH THE CATHOLIC HEALTHCARE ASSOCIATION GUIDELINES EACH HOSPITAL STRIVES TO MEET ITS COMMUNITY'S IDENTIFIED NEEDS. THE AVERA CENTRAL OFFICE ADVOCATES FOR ALL ON COMMUNITY BENEFIT RELATED MATTERS OF STATE, REGIONAL AND NATION IMPORTANCE. 1 MITCHELL TECH INSTITUTE FOUNDATION 821 N CAPITAL MITCHELL SD 57301 460452950 501(C)(3) 45000 DONATION UNIVERSITY OF SOUTH DAKOTA 414 E CLARK ST VERMILLION SD 57069 466018891 STATE OF SD 24000 DONATION MITCHELL CHARITABLE FOUNDATION PO BOX 1366 MITCHELL SD 57301 460390971 501(C)(3) 70000 DONATION DAKOTA WESLEYAN UNIVERSITY 1200 W UNIVERSITY AVE MITCHELL SD 57301 460224589 501(C)(3) 328500 DONATION MITCHELL SKATING & HOCKEY PO BOX 5 MITCHELL SD 57301 460425100 501(C)(3) 25000 DONATION LAKE AREA TECHNICAL INSTITUTE FOUNDATION 1201 ARROW AVENUE WATERTOWN SD 57201 363860861 501(C)(3) 21000 APPRAISAL DIMENSION XPAND CHEMISTRY ANALYZER DONATION 6 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION ONLY MAKES GRANTS TO OTHER ORGANIZATIONS WHICH ARE TAX-EXEMPT UNDER SECTION 501(C)(3). 0 0 0 0 0 0 0 0 0 PATRICIA MALTERS MD 222602 0 25650 0 19194 0 20300 0 476 0 288222 0 0 0 JENNIFER TEGETHOFF 223237 0 109289 0 671 0 20300 0 4221 0 357718 0 0 0 THOMAS CLARK 0 290779 0 0 0 79797 0 25956 0 21053 0 417585 0 0 WILLIAM E FLETT 133942 0 2240 0 318 0 10455 0 22723 0 169678 0 0 0 BRIAN KAMPMANN MD 605931 0 187263 0 31103 0 20300 0 22615 0 867212 0 0 0 STEPHEN DICK MD 344967 0 70013 0 8457 0 20300 0 20563 0 464300 0 0 0 CHRISTOPHER KROUSE MD 879737 0 96850 0 31111 0 20300 0 21126 0 1049124 0 0 0 MICHAEL HALEY MD 282009 0 227852 0 9020 0 20300 0 25010 0 564191 0 0 0 DENNIS LELAND MD 331298 0 293768 0 2912 0 20300 0 23585 0 671863 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I LINE 3: THE PRESIDENT/CEO'S COMPENSATION IS PAID BY A RELATED ORGANIZATION, AVERA HEALTH. AVERA QUEEN OF PEACE RELIED ON THE RELATED ORGANIZATION FOR DETERMINING THE COMPENSATION FOR THE PRESIDENT/CEO USING THE METHODS DESCRIBED IN PART I, LINE 3. PATRICIA MALTERS EMPLOYEE RECRUITMENT X 30000 2590 0 1 1 DAVID MALTERS EMPLOYEE RECRUITMENT X 30000 2590 0 1 1 5180 DAVID MALTERS MD FAMILY MEMBER OF BOARD MEMBER 237449 COMPENSATION 0 JAMES VALLEY IMAGING LTD BOARD MEMBER IS 33% OWNER OF CORPORATION 59163 PAYMENT FOR MEDICAL DIRECTOR SERVICES 0 ANDREA MALTERS FAMILY MEMBER OF BOARD MEMBER 28328 COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 2 SISTER KATHLEEN CROWLEY HAS A BUSINESS RELATIONSHIP WITH THOMAS CLARK. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS AVERA HEALTH, A NONPROFIT CORPORATION ORGANIZED AND EXISTING UNDER THE LAWS OF THE STATE OF SOUTH DAKOTA AND EXEMPT UNDER 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. FORM 990, PART VI, SECTION A, LINE 7A AVERA HEALTH, AS THE SOLE MEMBER, HAS THE POWER TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B AVERA HEALTH HAS THE FOLLOWING RIGHTS AS THE MEMBER. 1) TO APPROVE THE ADOPTION, AMENDMENT OR REPEAL OF THE STATEMENTS OF PHILOSOPHY, MISSION AND VALUES OF CORPORATION; 2) TO INITIATE THE ADOPTION, AMENDMENT OR REPEAL OF ANY PROVISION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF CORPORATION, AND TO GIVE FINAL APPROVAL OF ANY SUCH ACTION WITH RESPECT THERETO; 3) TO APPROVE AND ACT UPON THE ALIENATION OF REAL PROPERTY AND PRECIOUS ARTIFACTS UNDER THE CANONICAL STEWARDSHIP OF THE SISTERS OF THE PRESENTATION OF THE BLESSED VIRGIN MARY OF ABERDEEN, SOUTH DAKOTA ("PRESENTATION SISTERS") OR THE BENEDICTINE SISTERS OF SACRED HEART MONASTERY ("BENEDICTINE SISTERS"), PURSUANT TO THE POLICIES ESTABLISHED BY THE MEMBER; 4) TO APPROVE ANY PLAN OF MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION, OR THE DIVESTITURE OF A SPONSORED WORK OR MINISTRY ASSOCIATED WITH THE CORPORATION; 5) TO APPROVE THE CREATION OF NEW SPONSORED WORKS OR MINISTRIES TO BE CONDUCTED BY OR UNDER THE AUTHORITY OF THE CORPORATION; 6) TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE BOARD OF DIRECTORS OF THE CORPORATION. 7) TO APPOINT AND/OR REMOVE, WITH OR WITHOUT CAUSE, THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE CORPORATION. 8) TO APPROVE OPERATING/CAPITAL BUDGETS AND STRATEGIC PLANS OF THE CORPORATION. 9) TO APPROVE EXPENDITURES OUTSIDE OF OPERATING AND CAPITAL BUDGETS EXCEEDING DEFINED THRESHOLDS ACCORDING TO POLICY WHICH MAY BE ADOPTED FROM TIME TO TIME BY THE MEMBER. 10) TO APPROVE ACQUISITIONS, SALES AND LEASES, ACCORDING TO POLICY WHICH MAY BE ADOPTED FROM TIME TO TIME BY THE MEMBER. 11) TO ESTABLISH AND MAINTAIN EMPLOYEE BENEFIT PROGRAMS. 12) TO ESTABLISH AND MAINTAIN INSURANCE PROGRAMS. 13) TO APPROVE MAJOR COMMUNITY FUND DRIVES. 14) TO APPROVE THE APPOINTMENT OF AUDITORS. 15) TO ADOPT POLICIES DESIGNED TO EFFECTUATE THE RESERVED POWERS OF THE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED INITIALLY BY THE CFO. THE RETURN IS MADE AVAILABLE TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES. AT EACH BOARD MEETING, A REQUEST IS MADE FOR ALL BOARD MEMBERS TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST PERTAINING TO ANY ITEM LISTED ON THE AGENDA OR PERTAINING TO ANY POTENTIAL ITEM THAT COULD BE DISCUSSED DURING THE COURSE OF THE MEETING. THE DECLARATION OF CONFLICT OF INTEREST IS RECORDED IN THE MEETING MINUTES. THE BOARD MAKES A DETERMINATION OF WHETHER THERE IS A CONFLICT OF INTEREST AND IF SO, IMPLEMENTS THE PROCEDURE FOR EVALUATING THE ISSUE OR TRANSACTION INVOLVED. THE BOARD MEMBER OR OFFICER WITH THE CONFLICT MUST REFRAIN FROM VOTING. A STATEMENT OF CONFLICT OF INTEREST DISCLOSURE IS MADE ON AN ANNUAL BASIS BY OFFICERS AND DIRECTORS. THE INFORMATION IS MAINTAINED IN A DATABASE AND A REPORT IS PROVIDED TO THE BOARD. THE CEO IS COMPENSATED BY AVERA HEALTH. ANNUALLY THE COMPENSATION COMMITTEE OF AVERA HEALTH, WHICH IS COMPRISED OF SIX (6) SYSTEM MEMBERS APPOINTED BY THE RELIGIOUS ORDERS, MEETS WITH AN INDEPENDENT CONSULTANT REGARDING FAIR MARKET VALUE OF OFFICERS AND KEY EMPLOYEES. THE COMPENSATION COMMITTEE APPROVES ALL SALARIES BASED ON COMPARABLE DATA AND DOCUMENTS THE BASIS FOR THEIR DECISION IN MEETING MINUTES. THE COMPENSATION OF THE SENIOR VP OF FINANCE IS DETERMINED BY HUMAN RESOURCES BASED ON A MARKET ANALYSIS OF COMPARABLE POSITIONS. THE COMPENSATION IS APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE GENERAL PUBLIC. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 PER IRS INSTRUCTIONS AND THEREFORE ARE AVAILABLE TO THE GENERAL PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CAPITAL CONTRIBUTIONS, NET -2,600,951. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 984,972. FORM 990, PART XII, LINE 2C: THE AUDIT COMMITTEE OF AVERA HEALTH, PARENT ORGANIZATION, SELECTS THE AUDITOR AND REVIEWS THE AUDITED FINANCIAL STATEMENTS FOR AVERA QUEEN OF PEACE. FORM 990, PART X, LINE 20: THE ISSUE PRICE INCLUDES THE FILING ORGANIZATION'S SHARE OF THE ENTIRE BOND ISSUE, WHICH WAS ISSUED TO AVERA HEALTH ON BEHALF OF THE AVERA OBLIGATED GROUP. THE AVERA OBLIGATED GROUP CONSISTS OF AVERA HEALTH, AVERA MCKENNAN, AVERA ST. LUKE'S, AVERA QUEEN OF PEACE, AVERA MARSHALL, AVERA ST. MARY'S, AND AVERA SACRED HEART. IN ACCORDANCE WITH IRS INSTRUCTIONS, INFORMATION RELATED TO THE TAX EXEMPT BOND REPORTING IS BEING REPORTED ON AVERA HEALTH'S TAX RETURN (EIN 46-0422673). AVERA HEALTH 3900 WEST AVERA DRIVE SUITE 300 SIOUX FALLS SD 57108 460422673 PROMOTION OF HEALTH SD 501(C)(3) LINE 9 N/A 0 AVERA GETTYSBURG 606 EAST GARFIELD GETTYSBURG SD 57442 460234354 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA ST MARY'S 0 AVERA ST ANTHONY'S HOSPITAL 300 N 2ND STREET ONEILL NE 68763 470463911 HEALTHCARE EDUCATION NE 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA HOLY FAMILY 826 NORTH 8TH STREET ESTHERVILLE IA 51334 420680370 HEALTHCARE SERVICES IA 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA HOLY FAMILY FOUNDATION 826 NORTH 8TH STREET ESTHERVILLE IA 51334 421317452 FUNDRAISING IA 501(C)(3) LINE 9 AVERA HOLY FAMILY 0 AVERA MARSHALL 300 S BRUCE STREET MARSHALL MN 56258 410919153 HEALTHCARE SERVICES MN 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA MARSHALL FOUNDATION 300 S BRUCE STREET MARSHALL MN 56258 411784801 FUNDRAISING MN 501(C)(3) LINE 7 AVERA MARSHALL 0 ST BENEDICT HEALTH CENTER 401 WEST GLYNN DRIVE PARKSTON SD 57366 460226738 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 ST BENEDICT HEALTH CENTER FOUNDATION WEST GLYNN DRIVE PO BOX B PARKSTON SD 57366 460458725 SUPPORT HEALTH RELATED SERVICES SD 501(C)(3) LINE 11A, I ST BENEDICT HEALTH CENTER 0 AVERA MCKENNAN 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 460224743 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 SACRED HEART HEALTH SERVICES 501 SUMMIT STREET YANKTON SD 57078 460225483 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA ST MARY'S 801 EAST SIOUX AVENUE PIERRE SD 57501 460230199 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 HEALTH MANAGEMENT SERVICES 501 SUMMIT STREET YANKTON SD 57078 460399291 ADULT DAYCARE AND HOMEMAKING SERVICES SD 501(C)(3) LINE 9 SACRED HEART HEALTH SERVICES 0 LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY 1000 W 4TH STREET SUITE 9 YANKTON SD 57078 460337013 HEALTHCARE EDUCATION SD 501(C)(3) LINE 9 SACRED HEART HEALTH SERVICES 0 AVERA ST LUKE'S 305 SOUTH STATE STREET ABERDEEN SD 57401 460224598 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 Q&M PROPERTIES LLC 525 NORTH FOSTER MITCHELL SD 57301 731652049 MEDICAL CLINIC BUILDING SD AVERA QUEEN OF PEACE RELATED -512 397766 0 1 0.50000 AVERA HOME MEDICAL EQUIPMENT LLC 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 460488198 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A MRIS LLC 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 470874983 HEALTH CARE SERVICES INCLUDING AIRCRAFT SD N/A HOME MEDICAL EQUIPMENT OF PIERRE LLC 329 E DAKOTA PIERRE SD 57501 460444002 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF FLOYD VALLEY HOSPITAL LLC 714 LINCOLN ST NE LEMARS IA 51031 820582350 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF ESTHERVILLE LLC PO BOX 5045 SIOUX FALLS SD 57117 201686097 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF SIOUX CENTER LLC 38 19TH ST SW SIOUX CENTER IA 51250 753203100 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF MARSHALL LLC 1104 EAST COLLEGE DRIVE MARSHALL MN 56258 205271924 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF SPENCER HOSPITAL LLC 2400 S MINNESOTA AVE 102 SIOUX FALLS SD 57117 800619999 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A SURGICAL ASSOCIATES ENDOSCOPY CLINIC LLC 310 S PENNSYLVANIA ST ABERDEEN SD 57401 460461429 SURGICAL ASSOCIATES SD N/A HEART HOSPITAL OF SOUTH DAKOTA LLC 10720 SIKES PLACE SUITE 300 CHARLOTTE NC 28277 562143771 HEALTHCARE SERVICES NC N/A ACCOUNTS MANAGEMENT INC 5132 S CLIFF AVE SUITE 101 SIOUX FALLS SD 57108 460373021 COLLECTION AGENCY SD N/A C 0 AVERA HEALTH PLANS INC 3900 WEST AVERA DRIVE SUITE 101 SIOUX FALLS SD 57108 460451539 HEALTH FINANCING AND HEALTH PLAN ADMINISTRATION SD N/A C 0 AVERA PROPERTY INSURANCE INC 610 W 23RD ST STE 1 PO BOX 38 YANKTON SD 57078 460463155 INSURANCE SD N/A C 0 DR DONALD & MARGUERITE MABEE TRUST C/O FIRST NATIONAL BANK OF SOUTH DA MITCHELL SD 57301 466056202 INVESTING SD AVERA QUEEN OF PEACE HOSPITAL T 78753 797190 1.00000 1 VALLEY HEALTH SERVICES 501 SUMMIT STREET YANKTON SD 57078 460357149 RENTAL REAL ESTATE SD N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1